1.
The Welsh NHS Confederation, on behalf of its members,
wholeheartedly welcomes the opportunity to respond to the inquiry
into the general principles of the Public Health (Wales) Bill.

2.
By representing the seven Health Boards and three NHS Trusts in
Wales, the Welsh NHS Confederation brings together the full range
of organisations that make up the modern NHS in Wales. Our aim is
to reflect the different perspectives as well as the common views
of the organisations we represent.

3.
The Welsh NHS Confederation supports our members to improve health
and well-being by working with them to deliver high standards of
care for patients and best value for taxpayers’ money. We act
as a driving force for positive change through strong
representation and our policy, influencing and engagement work.
Member’s involvement underpins all our various activities and
we are pleased to have all Local Health Boards and NHS Trusts in
Wales as our members.

4.
The Welsh NHS Confederation and its members are committed to
working with the Welsh Government and its partners to ensure there
is a strong NHS which delivers high quality services to the people
of Wales.

Summary

5.
Due to the short time frames for responding to the Public Health
(Wales) Bill we are not providing detailed answers to all the
questions posed at this stage. We will be providing a more detailed
response by the closing date, September 4th, but thought it would
be beneficial for the Committee to receive comments before the oral
evidence session with the Directors of Public Health from Local
Health Boards and Public Health Wales NHS Trust on July
9th. The Welsh NHS Confederation also endorses the
written submission that has been provided to the Committee by
Public Health Wales NHS Trust and from the Executive Directors of
Public Health of the seven Welsh Health Boards.

6.
As with our response to earlier consultations relating to this
Bill,[i]
the Welsh NHS Confederation believes that the Public Health (Wales)
Bill provides a golden opportunity to improve the health of the
population. The NHS in Wales supports the Bill and is committed to
the protection and improvement of the health of the people of Wales
and the reduction of health inequalities. All health systems across
the UK should work to reduce premature mortality from preventable
disease, but this is particularly the case in Wales, which has
historically suffered from high levels of chronic ill health.

7.
While the Welsh NHS Confederation wholeheartedly supports the Bill,
we are disappointed that it does not include a clear and simple
preamble which sets out the goals and principles of the law. It is
vital that there is a clear vision of what the Bill intends to
achieve and the outcomes on which its success will be measured.
Health concerns need to be owned across Government departments and
by all sectors across Wales. The Well-being of Future Generations
(Wales) Act will go some way in ensuring that public bodies work
collaboratively to achieve a “healthier Wales”, it is
also essential that the Public Health (Wales) Bill places duties on
Welsh Ministers and public sector bodies to consider health in all
policies and developments which may impact on the health and
well-being of the people of Wales.

Part 2: Tobacco and Nicotine
Products

Do you agree that the use of e-cigarettes should be banned in
enclosed public and work places in Wales, as is currently the case
for smoking tobacco?

8.
The Welsh NHS Confederation agrees that the use of e-cigarettes
should be banned in enclosed public and work places in Wales.
While we acknowledge there is limited
evidence in relation to the impact of banning e-cigarettes on
smoking prevalence, we also acknowledge that legislating against
their use in enclosed public places would provide a clear and
consistent approach across Wales. This has the potential to
positively impact on the enforcement of current smoke-free
legislation and will ‘de-normalise’ smoking.

9.
While the current research in relation to the use of e-cigarettes
is limited, due to their perceived safety, glamorised use and
general appeal, the risk remains that e-cigarette use can act as a
potential gateway to tobacco products and could
‘normalise’ smoking behaviour and nicotine use. This is
particularly relevant to young people in Wales. A number of our
members believe that the use of
e-cigarettes in enclosed public places risks
‘normalising’ smoking and sends out mixed messages
about the impact that nicotine has on people’s
health.

10. A
number of strategies have been adopted or are being considered to
achieve this ‘de-normalisation’ including; prohibition
of tobacco advertising, promotion or sponsorship; a ban on smoking
in enclosed public spaces, tobacco display ban regulation and
standardised packaging. The widespread use of e-cigarettes in
public places and their uncontrolled marketing and promotion is
likely to undermine the attempts to ‘de-normalise’
smoking behaviour. E-cigarette companies are adopting many of the
advertising, promotion and sponsorship approaches of the tobacco
industry. This is resulting in advertising of nicotine vaping
products, which in some cases closely resemble cigarettes. Evidence
from the tobacco field has demonstrated that children and young
people are receptive to these messages.

11.The use of e-cigarettes in enclosed
public places has the potential to undermine some of the important
health gains that have been achieved through the smoking ban in
public places. It is very difficult for individuals to
differentiate between those smoking tobacco and those using
e-cigarettes, therefore making enforcement difficult. Many
e-cigarettes look similar to regular cigarettes, making people wary
of challenging smokers where bans exist. The use of e-cigarettes in
enclosed public places sends mixed messages to the public about
smoking acceptance. This has the potential to cause public
confusion and undermine the enforcement of smoke-free legislation.
The ban on smoking in enclosed public places has been successfully
applied in Wales and there is no evidence to suggest that similar
legislation relating to the use of e-cigarettes would not have
similar compliance. Legislation on the use of these products would
provide much needed clarity to ensure a consistent message across
Wales.

What are your views on extending restrictions on smoking and
e-cigarettes to some non-enclosed spaces (examples might include
hospital grounds and children’s playgrounds)?

12.
We would support extending the restrictions on smoking and
e-cigarettes to some non-enclosed spaces. While there is evidence
of voluntary bans being effective in some areas, at present,
without legal backing, voluntary behaviours are difficult to
enforce. Legislation would send a clear message around smoking
being prohibited in these areas and make consistent enforcement
much easier. This is particularly relevant in hospital grounds
where vulnerable patients are exposed to second-hand smoke from
those who refuse to heed the local policies. Ironically many people
require NHS services directly because of smoking induced diseases
such as cancers of lung, head and neck and gastrointestinal tract,
heart diseases, stroke and vascular (circulatory) diseases. Many of
these diseases cluster in areas of high deprivation and high
smoking prevalence. ‘De- normalising’ smoking is
essential if this burden on NHS resource is to be tackled.

Do you believe the provisions in the Bill will achieve a balance
between the potential benefits to smokers wishing to quit with any
potential disbenefits related to the use of e-cigarettes?

Do you have any views on whether the use of e-cigarettes
renormalises smoking behaviours in smoke-free areas, and whether,
given their appearance in replicating cigarettes, inadvertently
promote smoking?

13.
It is difficult to fully answer this question based upon the
existing body of evidence. However, as previously highlighted, we
believe that the use of e-cigarettes, which can mimic the act of
smoking, can help ‘normalise’ tobacco smoking. Their
use has the potential to undermine smoking prevention and cessation
activity and the important gains that have been achieved in this
area to date because e-cigarettes do include nicotine, with some
delivering a higher dose of nicotine than cigarettes. Through the
Bill there will be a clear and consistent message that smoking
(whether of conventional cigarettes or e-cigarettes) is
harmful.

14.
If we wish to reduce the chances of e-cigarettes becoming a gateway
for non-smokers into nicotine addiction or the use of conventional
tobacco products, our efforts need first to concentrate upon
restricting the marketing and promotion of these devices as many
young people do not recognise how susceptible they actually are to
the advertising that continually surrounds them. Consideration
should be given to potentially banning the use of e-cigarettes that
resemble conventional tobacco products in order to eliminate, or at
least minimise, confusion over the nature of the product. Hospital
smoke free wardens find it very difficult to distinguish between
normal cigarettes and some e-cigarettes that mimic appearance of
traditional cigarettes. It would be impossible to allow some
e-cigarettes and not others.

Do you have any views on whether e-cigarettes are particularly
appealing to young people and could lead to a greater uptake of
their use among this age group, and which may ultimately lead to
smoking tobacco products?

15.
We believe that e-cigarettes can act as a gateway to conventional
tobacco by appealing to young people and giving the impression that
they are a safe alternative, even though they still include
addictive and high levels of nicotine. The presentation of
e-cigarettes as a safe way to smoke may provide a route to nicotine
addiction for children and young people. This is not something to
be encouraged and is something that seems to be overlooked in much
of the debate and discussion about e-cigarettes. While they may be
preferable to smoking tobacco, their use is not something to be
encouraged, regardless of whether this leads to use of other
nicotine products or not. In addition, it is possible that once
established nicotine addiction through e-cigarettes it could lead
to tobacco use, although it will be some time before reliable
evidence is available that either supports or refutes these
concerns.

16.
There is little research evidence available on the use of
e-cigarettes among young people in the UK, given that the product
is still relatively new to the market and the rapid growth in their
use has only been within the last three to four years. However the
largest international dataset on use of e-cigarettes by young
people comes from the USA National Youth Tobacco Survey (NYTS)
which evidences a statistically significant increase of
e-cigarettes use by students from 2011–2014. This is a
survey[ii]
of a representative sample of 22,000 middle school (11 – 14
years) and high school children (14 – 18 years) across all 50
US States. The survey showed that e-cigarettes was the product most
commonly used by high school students (13.4%) and middle school
students (3.9%), with cigarettes third most common for high school
students (9.2%) and middle school students (2.5%). The biggest
concern about the survey is that the current e-cigarette use among
high school students increased from 4.5% (660,000 students) in 2013
to 13.4% (2 million students) in 2014. Among middle school
students, current e-cigarette use more than tripled from 1.1%
(120,000 students) in 2013 to 3.9% (450,000 students) in 2014. The
conclusions from the survey around the implications for public
health practice was that due to the rise in the number of students
using e-cigarettes it is critical that comprehensive tobacco
control and prevention strategies for youths should address all
tobacco products and not just cigarettes. Also worrying from the
earlier 2012 USA National Youth Tobacco Survey was that while the
data suggests that e-cigarette use is largely among tobacco
smokers, 20.3% of 11-14 year olds and 7.2% of 14 – 18 year
olds were previously non-smokers.

17.
We are also concerned about the extent and nature of tobacco
industry involvement in the development of the e-cigarette market,
and the role of commercial interests in recruiting new and
potentially young customers.

Do you have any views on whether restricting the use of
e-cigarettes in current smoke-free areas will aid managers of
premises to enforce the current non-smoking regime?

18.
In relation to the use of e-cigarettes on hospital grounds,
legislation would provide a clear message that smoking is not
allowed and would aid managers of premises to enforce the current
non-smoking regime. This would help strengthen the existing role
that NHS staff members currently play in enforcing the voluntary
ban on hospital grounds through providing staff with legal backing.
A number of our members have voluntary bans across hospital grounds
but it is difficult to enforce and it requires a high level of
multi-disciplinary support throughout the NHS in Wales. With legal
policies in place much of our members’ local implementation
of the voluntary ban would be considerably easier.

19.
While we support extending restrictions to some non-enclosed
spaces, it is vital that those enforcing the Bill are resourced
properly because it will require increased support.

Do you agree with the proposal to establish a national register of
retailers of tobacco and nicotine products?

Do you believe the establishment of a register will help protect
under 18s from accessing tobacco and nicotine products?

20.
We agree with the proposal of establishing a national register of
retailers of tobacco and nicotine products. Such a register could
strengthen the tobacco control agenda in Wales and the proposal is
in line with the Tobacco Control Action Plan for Wales. The role of
the register in preventing access to tobacco among children is also
recognised.

21.
We believe that the proposal to establish a register will help
protect under 18s from accessing tobacco and nicotine products. A
recent survey in England showed that nearly half of young smokers
(44%) reported being able to purchase tobacco from retail premises
despite the ban on the sale of tobacco products to those under the
age of 18.[iii]
The register would be an important step towards reducing the number
of young people in Wales who become smokers because they will only
be able to access tobacco or nicotine produces from registered
retailers. Creating a tobacco retail register will also help
colleagues in Trading Standards to tackle the problem of under-age
sales.

22.
The additional information which could be gathered by a
registration scheme will support enforcement of under-age sales and
assist in enforcement of the display ban by making it easier to
identify locations where tobacco is not permitted to be sold.
However, while supportive, we have concerns about the resourcing of
this initiative centrally and in Local Authorities. Unless the
proposal is properly funded, there may be unintended consequences
on other critical public health enforcement activity.

Do you believe the proposals relating to tobacco and nicotine
products contained in the Bill will contribute to improving public
health in Wales?

23.
We do believe that the proposals relating to tobacco and nicotine
products contained in the Bill will contribute to improving public
health in Wales.

24.
Additional proposals that our members have put forward around
tobacco and nicotine products include:

·
E-cigarettes, like tobacco products, should be subject to plain
packaging;

·
Shops / cafes should be prevented from opening for the sole purpose
of selling e-cigarettes and allowing their use within the
premises;

·
Primary care contractors, such as community pharmacies, should be
prevented from selling e-cigarettes;

·
There is a need to establish new definitions of smoking status
which take account of the widespread use of e-cigarettes and enable
population health surveys such as the Welsh Health Survey and
patient information systems to accurately distinguish between
non-smokers and ex-smokers who are no longer using nicotine
products from those who are adopting longer term harm minimisation
approaches;

·
Ensuring that, where relevant and appropriate, e-cigarettes are
subject to the same regulations regarding advertising and marketing
as conventional cigarettes (including minimising the attractiveness
of dangerous products to children and young people); and

·
Adopting a clear position regarding the future research needed to
establish the impact of e-cigarettes at population and individual
level.

Part 3: Special
Procedures

25.
We welcome and the introduction of a compulsory national licensing
system for practitioners of specified ‘special
procedures’ in Wales and that the premises from which the
practitioners operate these procedures must be approved.
Incompetent practices and procedures can lead to a burden on the
NHS which has to pick up short and long term sequelae, as evidenced
by the recent serious skin infection cluster necessitating a
blood-borne virus look-back exercise in Aneurin Bevan University
Health Board. One premise alone created a burden of work for the
Health Board that required considerable financial and human
resource to address.

26.
Such a register would be beneficial in recognising legitimate
practitioners and businesses and help to regulate these procedures
in Wales. A national licensing system for practitioners and the
mandatory licensing conditions which they have to comply with will
ensure the provision of consistent standards in respect of
infection control, cleanliness and hygiene for all practitioners
and businesses operating any of the listed treatments. It will be
essential that competency to perform certain procedures is tested.
Almost all GPs and Dentists would not attempt any procedure on the
human tongue without full resuscitation facilities available due to
the risk of haemorrhage and airway obstruction. Dentists are seeing
tongue piercings that have gone wrong on a regular basis.

27.
We support the definition of the ‘special procedures’
included within the Bill (acupuncture, body piercing, electrolysis
and tattooing), however this Bill also presents an opportunity to
regulate the administration of the following procedures: body
modification (to include stretching, scarification, sub-dermal
implantation/3D implants, branding and tongue splitting), injection
of any liquid into the body, for example botox or dermal fillers,
dental jewellery, chemical peels, and laser treatments such as used
for tattoo removal or in hair removal. It is important that, due to
the rapidly changing environment, that the legislation is flexible
enough to include other procedures in the future.

28.
We would also like this Bill to go further by requiring those
registering to undertake such procedures to meet national
standardised training where criteria of competency will have been
met, including hygiene standards, age requirements and ensuring
that they have no criminal background that would make them
unsuitable to undertake ‘special procedures’ (for
example Child Protection and CRB checks). We would advise that
registration should include mandatory proof of identity of the
practitioner. These measures would ensure that they have the
knowledge, skills and experience needed to perform these
procedures.

Part 4: Intimate
Piercing

29.
We support the proposals within the Bill that prohibits the
intimate piercing of anyone under the age of 16 in Wales. This will
aid in protecting the public and ensure a clear and consistent
message across Wales. The recent look back exercise in Wales
demonstrates that intimate piercing is not uncommon in this age
group and we welcome the outlawing of intimate piercing
irrespective of parental consent. We would encourage mandatory
proof of age for any client undergoing a ‘special
procedure’ or intimate piercing. It should be noted with
concern that girls as young as 13 had undergone nipple piercing in
the recent Gwent look-back exercise.

30.
We would recommend that the list of intimate body parts includes
tongue piercing because of the risks associated, including
infection, chipped teeth, blood poisoning, tongue swelling and
blood loss which may cause a risk to someone’s airways.
Through the Bill children and young people will be protected from
the potential health harms which can be caused by intimate
piercing. Competency checks will also be required before nipple,
genital and tongue piercing, and before body modification such as
ear cartilage removal, tongue splitting and branding. Currently
there are no checks on the ability of the practitioner to conduct
these forms of minor surgery which are much more invasive than most
minor surgery performed in primary care for which General
Practitioners need additional qualifications.

Part 5: Pharmaceutical
Services

Do you believe the proposals in the Bill will achieve the aim of
improving the planning and delivery of pharmaceutical services in
Wales?

31.
The proposals in the Bill will achieve the aim of improving the
planning and delivery of pharmaceutical services in Wales. The
Welsh NHS Confederation is pleased to note that the Bill recognises
the important role that pharmacists can play in improving the
health and well-being of the public. Requiring Health Boards to
prepare and publish an assessment of the need for pharmaceutical
services in its area is a step towards integrating pharmaceutical
care and pharmaceutical services into the planning processes of the
Health Board. Community pharmacies should play a stronger role in
promoting and protecting the health of individuals, families and
local communities as part of a network of local health care
services.

32.
The pharmaceutical needs assessments need to be tightly integrated
into the Health Board Integrated Medium Term Plan (IMTP) cycle,
driving planning and delivery of services. The pharmaceutical needs
assessment will likely consist of information which is already in
the local health and well-being needs assessment (and therefore not
need to be duplicated), along with information on services
currently being provided through pharmacies and their locations.
This latter new information might be best assessed in conjunction
with the location and accessibility of other NHS services, for
example primary care and hospital services.

33.
Pharmaceutical needs assessments should examine the demographics of
their local population, across the area and in different
localities, and their needs. Pharmaceutical needs assessments
should describe the pharmacies and the services they already
provide. These will include dispensing, providing advice on health,
medicines reviews and local public health services, such as stop
smoking, sexual health and support for drug users. They should
describe accessibility to these services, including by public
transport. Pharmaceutical needs assessments should look at other
services, such as dispensing by GP surgeries, and services
available in neighbouring areas that might affect the need for
services in its own area. They should examine whether there are
gaps that could be met by providing more pharmacy services, or
through opening more pharmacies. Over provision of pharmacies in
particular areas should be considered and the pharmaceutical needs
assessments should also take account of likely future needs.

Do you believe the proposals relating to pharmaceutical services in
the Bill will contribute to improving public health in Wales?

34.
The Welsh NHS Confederation agrees that there is considerable
public health benefit to be gained by ensuring that Local Health
Boards have a stronger role in planning pharmaceutical services in
their areas. Community services play an important role in
delivering public health services, including community pharmacies.
The Bill provides an opportunity to ensure that the public are
aware of the services that they can receive and access locally to
remain in good health.

35.
The Bill recognises the important role that community services can
play in delivering public health services. The NHS has historically
undervalued the role that community pharmacy can play in improving
and maintaining the public’s health. However, there is
increasing recognition that community pharmacists can make a
significant contribution to improving the public’s health.
Community pharmacy and the NHS share a common purpose in a number
of areas:

·
Public health, pharmacists and their teams already have a track
record in delivering public health services, such as promoting and
supporting good sexual health, reducing substance misuse within
communities, stop smoking services to help people quit and weight
management services to promote healthier eating and lifestyles;

·
Support for independent living, by helping people to understand the
correct use and management of medicines as well as provide healthy
lifestyle advice and support for self-care, pharmacists and their
teams can help contribute to better health, reduce admissions to
hospital and help people remain independent for longer;

·
Making every contact count, by using their position at the heart of
communities pharmacies can use every interaction as an opportunity
for a health-promoting intervention, as signposters, facilitators
and providers of a wide range of public health and other health and
well-being services.

36.
The NHS Confederation’s discussion paper ‘Health on the
high street: rethinking the role of community
pharmacy’[iv]
highlights that evidence is emerging around the potential role
community pharmacy can play in improving and maintaining the
nation’s health. The paper finds that, as trusted and
professional partners in supporting individual, family and
community health, sitting at the heart of our communities,
effective community pharmacy services have a significant and
increased role to play in ensuring we have a sustainable healthcare
system and that the NHS is able to survive and thrive over the
coming decades. However, this will require providers, patients and
the public to be more aware of community pharmacy’s role
alongside other primary and community care service, as highlighted
within the Health and Social Care Committee’s inquiry into
community pharmacies in August 2011. The Committee’s report
clearly demonstrated the contribution that community pharmacy can
have on the health service but better communication mechanisms are
needed to inform the general public about the services available at
any individual community pharmacy.

Part 6: Provision of
Toilets

37.
The Welsh NHS Confederation supports the requirement that each
Local Authority will have to prepare and publish a local toilets
strategy, which assesses the need for public toilets in its area,
and sets out steps that the authority proposes to take to meet that
need. The adequate provision of and access to toilets for public
use is an important public health issue.

38.
Accessible public toilets are a necessity to maintain population
health for everyone, but some groups have specific needs. These
include disabled people, parents with babies and young children,
pregnant women, older people and those with specific conditions
including incontinence, inflammatory bowel disease, irritable bowel
syndrome, multiple sclerosis and people who have been prescribed
diuretics. If toilet provision is inadequate, people can become
afraid or reluctant to go away from the home for periods of time,
leading to poor mobility, isolation and depression.[v]

39.
While the preparation of a strategy that considers the need for and
plans for the future provision of toilets for public use would
provide clarity at the local level (for elected members, officers
and the public) the real issue of making resources available to
address this remains. The duty on Local Authorities within the Bill
is that they “may provide toilets in its area for use by
the public” and the writing of a strategy alone will not
automatically improve provision because of the significant
financial pressures already experienced by Local Authorities.

40.
The statutory duty to write a strategy will have little impact on
actual provision, unless resources can be identified to put such a
strategy in place. This presents challenges in Local
Authorities’ ability to safeguard existing provision and to
promote new facilities. We believe that any additional duties
placed on Local Authorities should be adequately funded, as some
previous closures have been due to heavy maintenance and upgrading
costs. The preparation of a local strategy may not result in
improved provision and accessibility without adequate resources
provided to Local Authorities to implement such a strategy.

41.
In addition to the duties the Bill places on Local Authorities,
consideration and awareness needs to be increased around other
schemes. The public access Community Toilet Scheme introduced in
2009 is reportedly underused with large variation between Local
Authorities and some people are not comfortable with using this
type of facility. This is a scheme through which people can use the
toilet facilities in participating local businesses when they are
open, without having to make a purchase. However communication of
location and access to potential users can be inadequate and access
is necessarily limited to business opening hours.

42.
The problem of lack of street signage can also be an issue to
accessing public toilets. Signage should be standardised, showing
opening times and facilities available. Examples of alternative
sources of information which exist elsewhere include
Australia’s National Toilet Map, the UK disabled
drivers’ mapping portal and Westminster City Council’s
SatLAV, which allows visitors to text for their nearest toilet and
opening times.

Finance questions

43.
As highlighted above, some aspects of the Bill will need resourcing
and Local Authorities are likely to incur costs due to the
increased duties placed on them as a result of the Bill. It is
important that any requirement on local government is proportionate
to the issue. We recognise that, as with NHS services, severe
strain has been placed on local government services during the
economic downturn and that difficult choices have had to be made
around the prioritisation of services provided in local
communities, many of which are direct determinants of health. With
any new duty there is an opportunity cost around what can be
provided with limited resource.

Other comments

Food Standards

44.
The Welsh NHS Confederation is disappointed that regulation of food
standards in settings such as pre-school and care homes are not
included in the Public Health (Wales) Bill. Food standards can make
an important impact on public health. Good nutrition in very young
children is essential for future growth development and health,
while poor nutrition in care homes is likely to undermine their
health and well-being and increase the chances of the need for
health services intervention.

45.
We strongly are persuaded that this aspect could be strengthened so
that there is no missed opportunity to place mandatory food
standards on all food or drink supplied by or procured for settings
directly controlled, commissioned or inspected by public sector
organisations.

46.
Maintaining food standards, particularly in health settings such as
hospitals which seek to keep people well, can inform and influence
the public’s perception of what foods are considered
acceptable and healthy. The public sector caters for
some of the poorest and most vulnerable people in
society. Catering Standards for Food and Fluid
Provision for Hospital Inpatients, and the All Wales Hospital Menu
Framework standards ensure patients receive adequate nutrition to
assist with their recovery whilst in hospital, but there is much
work needed to make sure that healthy and balanced meals and food
are offered to all those accessing the restaurants (including
staff, patients and visitors). Mandated criteria for the provision
of only healthier retail items in hospital restaurants and outlets
would help hospitals in Wales to fulfil their responsibility for
improving the health of the population they serve.

47.
We would welcome the extension of the Welsh Government’s
Health Promoting Hospital Vending Directive into other public
sector settings, such as Local Authority premises including leisure
centres and community centres, and feel that there is also a need
to introduce food standards into the wider private sector.

A clear vision for the role public
health plays in Wales

48.
While the Welsh NHS Confederation supports the Bill, it is
disappointing that the vision and the outcomes that the Bill is
trying to achieve are not included. As it stands the Bill deals
with areas that could predominantly be dealt with through secondary
legislation and it does not include a clear vision which sets out
the goals and principles of the law. We believe it is important
that the Bill includes information to explain clearly to the public
that public health is everybody’s business, and not solely
confined to the NHS and the public sector.

49.
With the Public Health (Wales) Bill there is a once in a generation
opportunity to place public health at the centre of our public
policy and practice in Wales in order to enable people to live
healthy, long lives with a public service that is organised to
promote self-care, prevent ill-health and keep people healthier for
longer. The future success of the NHS relies on us all taking a
proactive approach to public health and ensuring that we create the
right conditions to enable people in Wales to live active and
healthy lifestyles.

50.
Through introducing this Bill we have an opportunity to make Wales
a nation that takes the health of its citizens very seriously.
There is an over-riding case for the Bill to take advantage of this
‘once in a lifetime opportunity’ to raise the profile
of public health in society. In addition we have the opportunity to
increase awareness and knowledge of public health across all
Government departments, and among those who develop and implement
policy, to support the population to live long, healthy and
independent lives.

To tackle public health issues we need
better integration

51.
It is vital that when considering public health issues, the Bill
ensures that all Government departments and public bodies work in
an integrated and holistic way. While the Well-being of Future
Generations Act 2015 goes some way to achieving this, it is
essential that the Public Health (Wales) Bill places a duty on
Welsh Ministers and public sector bodies to consider health in all
policies and developments which might impact upon the health and
well-being of the people of Wales.

52.
The Bill should ensure that the Welsh Government is obliged to
consider the impact on the health of the population in developing
and appraising policies in all Government areas. In addition to
Welsh Ministers, it is essential that the Bill places duties on all
public sector bodies to consider health in all policies and
developments which might impact on the health and well-being of the
people of Wales, for example closing or limiting access to leisure
centres, public transport and provision of safe green spaces.

53.
As the Welsh NHS Confederation’s ‘From Rhetoric to
Reality – NHS Wales in 10 years’ time’[vi]
highlighted, engagement with all our public service colleagues is
necessary to take us all from an ill health service that puts
unnecessary pressure on hospital services, to one that promotes
healthy lives. Engagement is necessary with all our public service
colleagues, from social care to housing, education and transport.
All public bodies in Wales must build on how we might improve our
ability to work together and support our partners and colleagues in
other sectors.

54.
The Public Health (Wales) Bill is a crucial first step in tackling
the culture of ill health in Wales recognising that health is much
more than health services. Better health is the responsibility of
all sectors and while the Welsh Government has already taken steps
to infuse health into various sectors through, for example,
legislation for children and young people, housing and active
travel, the Bill is an opportunity to progress this work further.
We believe through having health in all policies it will raise the
profile of public health in society, increasing awareness and
knowledge of important public health issues across government
departments and in all sectors.

People in Wales are empowered to take
control of their health

55.
Public health plays a key role in ensuring that we reduce demand
and empower people to take control of their health. The
introduction of this legislation can renew focus on prevention and
well-being and contribute to achieving prudent healthcare in NHS
Wales. However, to ensure that this is done people need to be
educated and empowered to have the knowledge and understanding to
remain in good health and receive appropriate interventions.

56.
We must continue to drive a mass shift in public thinking. In
relation to people in poor health, the NHS needs to communicate
with people and ensure that they are aware of the decisions that
they are making and how they are impacting on their health. In
terms of how services are used, the re-education of the public is
vital and we must involve the public fully in deliberating what the
NHS will and will not provide in future and we need to look at the
ways public bodies co-produce services with the public.

To improve public health it is
essential to tackle poverty

57.
Under the Public Health (Wales) Bill the Welsh Government should
provide greater consideration to the impact poverty has on the
health of the population. The importance of tackling poverty to
improve people’s health cannot be underestimated. Poverty and
deprivation are linked to many of the public health concerns and
outcomes in Wales.

58.
There are still significant health inequalities, including by age,
ethnicity and socio-economic group.[vii]
The Welsh NHS Confederation recently published the
‘Socio-economic deprivation and health’[viii]briefing.
This highlights the correlation between socio-economic deprivation
and people’s health and well-being outcomes, with the gap in
life expectancy for people living in the most deprived and the
least deprived areas of Wales currently stands at 9.2 years for men
and 7.1 years for women for all Wales.[ix]
In some Health Boards the discrepancy in healthy life expectancy
between the most and least deprived is over 20 years. Through
analysing trends across socio-economic groups we highlight how
deprivation has an impact on child development, people’s
lifestyle choices, healthy life expectancy, including living with
an illness or chronic condition, and life expectancy. It is now the
time for all public sector organisations, including the health
service, to work together to tackle deprivation and inequality.
Through the Public Health (Wales) Bill and the Well-being of Future
Generations (Wales) Act it is imperative that collaboration across
all public bodies improves to achieve a “healthier
Wales” and an “equal Wales”. We must
deliver a more integrated and preventative approach for our
public’s health that has maximum impact to reduce
inequalities and keep people healthier for longer.

Conclusion

59.
While the debate around this Bill has predominately focused on
e-cigarettes it is vital to recognise the key role that public
health plays in reducing health inequalities, ensuring positive
outcomes for the Welsh population and reducing demand on the NHS.
While the demand for NHS services will never go away, the point at
which the NHS intervenes has huge implications on both the cost and
quality of care provided. By working with public health
initiatives, and allowing the public to take more responsibility
for their own health, we can reduce the complexity, and therefore
the demand, of some of our highest need cases. Services in Wales
need to be integrated, person-centred, co-ordinated, community
based and focused on people’s well-being. We hope that the
Public Health (Wales) Bill goes some considerable way in helping to
achieve this.

[i] The Welsh NHS Confederation, June
2014. Response to the ‘Listening to you – Your health
matters’ White Paper.

[ii] USA National Youth Tobacco Survey,
April 2015. Tobacco Use Among Middle and High School Students
— United States, 2011–2014.

[iii] Health & Social Care Information
Centre, 2013. Smoking, drinking and drug use among young people in
England in 2012.

[iv] The NHS Confederation, 2013. Health
on the high street: rethinking the role of community pharmacy.

[v] Older Peoples Commissioner for Wales,
2014. The Importance and Impact of Community Services within
Wales.